Download Social Worker Interventions for Patients Post-Stroke

St. Catherine University
University of St. Thomas
Master of Social Work Clinical Research Papers
School of Social Work
5-2014
Social Worker Interventions for Patients PostStroke
Alexander Carlson
St. Catherine University
Recommended Citation
Carlson, Alexander, "Social Worker Interventions for Patients Post-Stroke" (2014). Master of Social Work Clinical Research Papers.
Paper 300.
http://sophia.stkate.edu/msw_papers/300
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Social Worker Interventions for Patients Post-Stroke
By
Alexander Carlson, B.A.S.
MSW Clinical Research Seminar
Presented to the Faculty of the
School of Social Work
St. Catherine University and the University of St. Thomas
St. Paul, Minnesota
in Partial fulfillment of the Requirements for the Degree of
Master of Social Work
Committee Members
Michael Chovanec, Ph. D., LICSW, LMFT (Chair)
Tanya Rand, LICSW
Jodi Greenstein, LICSW
The Clinical Research Project is a graduation requirement for MSW students at St. Catherine
University/University of St. Thomas School of Social Work in St. Paul, Minnesota and is
conducted within a nine-month time frame to demonstrate facility with basic social research
methods. Students must independently conceptualize a research problem, formulate a research
design that is approved by a research committee and the university Institutional Review Board,
implement the project, and publicly present the findings of the study. This project is neither a
Master’s thesis nor a dissertation.
i
Abstract
Research suggests that when a patient experiences a stroke, the lives of the patient and
family of the patient can be impacted in many different ways. The purpose of this project was to
identify the ways social workers work with stroke patients in the hospital, and how do they
identify mental health symptoms in these patients. Using a qualitative design, four social
workers, currently providing services in hospitals were interviewed. Data was analyzed using
deductive approaches in which themes were developed from the interview responses. The
findings indicated that most mental health symptoms are identified in patients, and then treated
once the patient leaves hospitalization. Also, social workers have ways to identify general mental
health themes, but do not have a standard mental health inventory or screen. The findings
demonstrate that stroke patients and families of the patients may be overwhelmed, but still need
support and compassion. This support could come from the social worker assigned to the family,
or possibly from a volunteer in order to help normalize and care for the patient.
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Acknowledgements
I would like to acknowledge my research chair Mike Chovanec, Ph. D., LICSW, LMFT,
as well as my committee members, Tanya Rand, LICSW and Jodi Greenstein, LICSW. Without
their tireless work, effort and dedication to this project, my research would likely have taken a
completely different direction. Innumerable topics, ideas and recommendations were given to
me, which created the ability to enrich and strengthen the research process. I am forever grateful
to you three for the time and assistance you provided to me through the year.
Additionally, I would like to thank my participants in this study, as well as the countless
hospital social workers providing care to stroke patients around the world. It takes a great level
of compassion, patience and knowledge to be able to connect with patients and patient care
systems who have just had their lives turned upside down. You all help to make a truly terrifying
and serious situation more comfortable for countless patients and families. We as patients cannot
thank you enough for all that you do.
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Dedication
I’d like to take the time to thank my friends and family; you all have been so patient and
motivating to me through this entire process. I’ve heard former students, supervisors and
professors say that it is necessary for MSW students to pick and choose how many times are able
to get together with friends and family, so as to leave enough time to complete studies. Many of
you have been so compassionate towards my requests for schedule changes and needs to decline
time spent together; I’ll never be able to demonstrate how truly appreciative this has been
necessary.
Thank you to Pandora for having free classical music for me to get my mind in order
when I’ve been anxious about this project.
A special thank you to my wife Mallory and my father Greg. Thank you so much for all
of the calls you’ve made to check in on me, conversations helping to calm me down, literally
keeping me alive and sane through my medical challenges, and all of the time spent helping me
with my household responsibilities. I love you both, and don’t know if I will ever be able to
thank you enough for all you have done for me.
Finally, thank you to my baby girl Hattie Grace. Daddy is finally done with his
homework, and can come play with you!
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Table of Contents
ABSTRACT
i
ACKNOWLEGEMENTS
ii
DEDICATION
iii
TABLE OF CONTENTS
iv
LIST OF TABLES
v
INTRODUCTON
1
LITERATURE REVIEW
6
CONCEPTUAL FRAMEWORK
15
METHODOLOGY
19
FINDINGS
25
DISCUSSION
35
LIMITATIONS AND RECOMMENDATIONS
39
CONCLUSION
45
REFERENCES
47
APPENDIXES
49
v
List of Tables
TABLE 1
27
TABLE 2
28
TABLE 3
29
TABLE 4
29
TABLE 5
30
TABLE 6
31
TABLE 7
32
1
Social Worker Interventions for Patients Post-Stroke
Introduction
A cerebrovascular accident (CVA), more commonly known as a stroke, is the most
frequently occurring medical condition in the United States leading to long-term disability
(Klinedinst et al.2012). CVA is also the third most prevalent cause of death in the United States
(Rizzo, 2006). Not only are CVA incidences frequent, but the onset of each occurrence also links
to a great number of resource utilization in hospitals and clinics (Riddoch et. Al., 1995). The
resources utilized not only come in the form of hospital staff, but also in increased economic cost
(Gabrielle, 2009). In a 1985 study, it was estimated that a patient living with the complications of
a CVA without receiving some sort of rehabilitation cost approximately $100,000 over the
course of their lifetime (Riddoch et. Al., 1995).
However, the experience of a stroke in somebody under the age of 30 years is a rare
occurrence. For example, consider the case of “Bob”. Bob is a 29 year old male who experienced
stroke at age 28. He has not experienced a stroke due to heart disease, arterial plaque buildup,
drug use, or any other lifestyle choice. The reason Bob experienced his stroke was due to a
congenital heart defect, which disallowed proper blood circulation. This defect allowed a blood
clot to travel through the chambers of his heart up into his brain. As a result, Bob experienced a
loss of his ability to walk, proper balance, and began to experience signs of anxiety and
depression. The mental health symptoms began presenting within a week of him being
discharged from the hospital. Bob regained his ability to walk over time, but his mental health
symptoms remained long after his increase in physical functioning. He returned to the hospital
and emergency room several times, unsure of whether or not he was experiencing another stroke,
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or the symptoms of a panic attack. Each time Bob was admitted to the emergency room, doctors
would evaluate his medical symptoms, and find that he was not having a stroke. Bob asked
doctors whether or not they thought he may be experiencing a panic attack or anxiety, but no
mental health evaluation was ever given.
A patient meeting these criteria would be within the 10th percentile in regards to average
age of CVA onset (Sila et. Al., 2011). CVA patients also frequently will need aftercare;
approximately 90% of the patients needing some type of medical or rehabilitative intervention,
leaving as few as 10% of the patients requiring little to no medical or rehabilitative interventions
(Riddoch et. Al., 1995). Not only do CVA patients experience a myriad of physical
complications and disabilities (i.e.: trouble with muscle atrophy, inabilities to use certain parts of
their bodies, attention, mood, concentration and cognition challenges, et cetra.), but mental
health problems can be a co-morbid condition accompanying a stroke (Klinedinst et. Al., 2012).
One of the most common mental health concerns facing post-stroke survivors is the condition of
post-stroke depression (Klinedinst, 2012). Post-stroke depression is generally considered to be a
lay term; post-stroke depression is classified by the Diagnostic Statistical Manual of Mental
Disorders (America Psychiatric Association, 2013) as a mood disorder due to a general medical
condition, as opposed to Major Depressive Disorder. The specifiers for this diagnosis generally
are identified as the patient having either depressive features, manic features, or a combination of
the two (Ros, 2009). In addition, some major depressive-like episodes can be experienced by the
patient rather than longer, more pervasive depressive symptoms.
One of the challenges which CVA patients clinically present is in differentiating whether
or not the emotional and behavioral changes exhibited are linked to the physical characteristic
changes in the brain, mood changes due to the patient’s new situation, or due to cognitive
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changes associated with aging (Klinedinst et. al., 2006). Working with stroke patients is a very
complex occupation; it requires skilled and knowledgeable professionals in order to discern
between all of the patient’s conditions. According to the literature, these challenges are some of
the reasons that post-stroke depression is largely unidentified and undiagnosed within the
population of CVA patients (Klinedinst et. al., 2006). In addition, Klinedinst et. al., (2006)
asserts that many CVA patients deliberately try to hide symptoms from clinicians, and not
enough primary care physicians are screening for depressive symptoms. It has been reported that
approximately one in three CVA sufferers will experience some form of depression after the
occurrence (Hackett et. al., 2006).
The major cause for concern is in the level of post-stoke counseling,
psychoeducation and mental health screening performed by my practitioners. When examining
the impact of a stroke on someone atypical from the average patient, challenges in the treatment
could arise. As Klinedinst asserts, CVA is the third most prevalent cause of death in the United
States (2012). With this high percentage, there is a greater likelihood that a social worker will
come into contact with this patient population at some point in their career. As social workers
tend to examine patients from the lens of the systems involved in the life of a patient, social work
insight is beneficial to the treatment of CVA patients.
Clinicians may declare that a 28 year old would likely have depression, and negatively
impacted cognitive abilities as a result of stroke. But what if this example stroke patient were to
begin returning to the hospital reporting of new symptoms? For example, what if said patient
expressed experiencing symptoms of a panic attack, that clinicians were unsure whether
symptoms were sign of another stroke, or were mental health changes? If these new symptoms
were so severe, this patient may present to the emergency room multiple times, repeated
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inquiries and consulting with many doctors, physician’s assistants, medical specialists and
medical interns. How much advocacy and speaking should a patient have to do for their mental
health symptoms to be addressed in addition to the ruling out of other medical conditions? What
would happen if the patient, as a result of the stroke, were now unable to communicate in a
verbal or written manner? These are just some possible challenges that a stroke patient may have
to experience.
Importance to Social Work
With the aforementioned prevalence of under-diagnosed and under-identified mental
health symptoms, as well as coordinating care and support for the patient, a clinical social
worker would be a great candidate for working with this population. A doctor/neurologist and a
clinical social worker could effectively collaborate in order to identify current and impending
concerns for stroke patients; this collaborative team could work to identify what issues may be
present for the patient as well as their support system. The need for social workers to have
experience working with stroke patients and support systems is necessary, due to the number of
people who will experience a CVA. A social worker is a great asset for a patient and the support
system of said patient due to the unique nature a social worker examines the challenges a patient
experiences. Medical doctors and neurologists present a great asset to the patient as identification
of the physical challenges presented by stroke have a large impact on outcome for the individual
in regards to rehabilitation (Fundukain, 2011). However, as aforementioned, behavioral health
and mental health rehabilitation are services which appear to be at a deficit for the rehabilitative
services to stroke patients. As clinical social workers are one of the larger populations providing
mental health resources, it is important for social workers to identify another subset of the
population who need rehabilitative services.
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Potential Implications for Social Work Practice, Policy, Further Research
Rizzo (2006) found that the CVA patient cases in her study revealed a moderate patient
improvement when being paired with social work services, as well as a decrease in the cost of
the patient to the hospital. This also asserts that the patients demonstrate some marked
improvement in situation when working with a social worker. One area the research aimed to
address was of ways a social worker could better the situations of the patient’s care system. For
example, after a stroke patient leaves hospitalization, do patients and care system still retain a
number of questions and concerns they want answered about the new medical condition, or
symptoms which may arise months later? These concerns may be marginally discussed during
hospitalization. However, if some questions and concerns are left unaddressed for the patient,
could a clinical social worker address these concerns, in addition to their other responsibilities to
the patient?
Purpose of Study/Questions to be Answered
The overall basis for this study was to determine how frequently stroke patients and their
corresponding care systems meet with social services, how effective are social work meetings at
reducing mental health systems for patients as well as caretakers, and whether or not any of the
hospitals or clinics studied have a required or recommended social work intervention for such
situations.
The research question for this proposal was to identify the challenges and interventions
experienced by stroke patients as viewed from a social work perspective. The researcher
interviewed hospital social workers practicing with patients who have experienced a stroke, in
order to gain more insight into what the social workers view as best practices.
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Literature Review
The literature regarding CVA, including general demographics, impact on patients, and
the implications Social Work practices have with said patients will be discussed. Topics will also
include how a CVA may impact mental and physical health in a patient, socioeconomic and
relational stressors, as well as the impact CVA presents with various resources.
General Information about Cerebrovascular Accident (CVA)
According to the Gale encyclopedia of medicine (Fundukain, 2011) a cerebrovascular
accident (i.e.: CVA) is a situation when blood flow to the brain is stopped for a period of time.
The blood flow can stop to any number of places in the brain, based on what artery or blood
vessel is blocked. Due to the different part of the brain being impacted, a multitude of different
symptoms can occur: memory problems, physical challenges or paralysis, cognitive and
personality changes, balance and coordination problems, speech challenges, et cetra (Fundukain,
2011). According to Gale (Fundukain, 2011), a stroke or CVA can result from one of four types:
cerebral and cerebral thrombosis, which is a block in an artery supplying the brain with blood, as
well as a subarachnoid or intracerebral hemorrhage, which is when an eruption or burst occurs
within the blood vessel. A cerebral embolism or thrombosis are a much more frequently
occurring variety of CVA, accounting for more than 70% of all CVA incidences (Fundukain,
2011). A preceding occurrence to a cerebral embolism or thrombosis is what is called a transient
ischemic attack, or TIA, in which the blood supply is temporarily cut off from the brain, and
stroke-like symptoms occur, but tend to go away within a short amount of time (Fundukain,
2011). TIA’s are reportedly a frequent precursor to experiencing a CVA, so if a person happens
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to experience stroke-like symptoms, it is highly advised that the person seek immediate medical
attention in order to prevent more damage (Fundukain, 2011).
According to the Gale encyclopedia (Fundukain, 2011) a stroke or CVA occurs to
approximately a half million citizens in the United States each year; impacting males aged 65+
the most frequently. Over 160,000 CVA patients die from the situations; almost one-third of all
stroke attacks, and stroke attacks are the third most prominent reason for death in the United
States (Fundukain, 2011 )Stroke attacks impact African American citizens more frequently than
any other ethnicity, and the instance of death in this subpopulation is the highest rate of
occurrence (Fundukain, 2011).
Caplan and Moelter’s (2000) study also makes assertions and identifies about what
happens to a patient when they have strokes in different regions of the brain. Caplan et. Al.
(2000) goes into greater detail about what the rehabilitation and assessment methods are most
beneficial to stroke patients, as opposed to describing in diagnostic terms of what has medically
changed with the patient. The functioning of a patient who has experienced stroke or CVA is
discussed in topics of psychological assessment, acute assessment, acute rehabilitation,
neuropsychological disorders and rehabilitation, impaired awareness, emotional disorders,
interventions with family and staff, and post acute assessment (Caplan et. Al., 2000). One
interesting assertion in the Caplan literature (2000) is that there is presented evidence to suggest
that “…psychosocial disabilities were more common than physical ones following stroke” (p.
88). The literature describes enlisting the help of a stroke psychologist in educating family and
support systems, medical staff, treatment teams, as well as advise the treatment and discharge
plan of the patient based on their specific clinical presentation (Caplan, 2000). The literature also
goes on to describe portions of hospitals which are designed to specifically target patients who
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have experienced stroke and CVA; the literature suggests that the quality of life for these patients
five years post-stroke is statistically better than for patients who received treatment for their
emergent issues within a general hospital setting (Caplan, 2000). The assessments administered
to the medical setting are manufactured to take in the general cognitive function of the average
stroke/CVA patient, (i.e. an older or elderly adult) as cognitive decline generally occurs with
older patients (Caplan, 2000). Caplan’s literature also asserts common psychological changes
which occur in stroke/CVA patients, including the fear of impending further strokes, death, selfreliance, dignity and a myriad of other concerns (2000). The condition known as post-stroke
depression, also known as depressive disorder due to a general medical condition (APA, 2013),
varies in patients who have experienced stroke/CVA, estimating that somewhere between 2979% of these patients will experience some form of depression, either from physical alterations
to the brain, cognitive changes about the patient’s situation, or a combination (Caplan, 2000).
There are several negative impacts on patients who experience post-stroke depression: extra time
spent hospitalized, increased challenges returning to their typical lives, and a decreased level of
functional recovery (Caplan, 2000). In addition to post-stroke depression, symptoms of anxiety
and agoraphobia were frequently diagnosed in patients post-stroke; most frequently observed
was generalized anxiety disorder at 24%, and agoraphobia in approximately 7-8% of patients
(Caplan, 2000). According to the literature, more research has been completed in the field of
post-stroke depression, as themes of the patient parts of their formal self, but there has been less
study about post-stroke anxiety (Caplan, 2000). Caplan states that anxiety generally results from
changes in daily living functioning and the amount of change in a person’s social and
conversational skills. It is mentioned that supportive counseling and problem-focused
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discussions can help to decrease anxiety symptoms, but the treatment of post-stroke anxiety is
not as heavily studied a topic as post-stroke depression (Caplan, 2000).
Ros (2009) describes the different portions of the cerebellum, as well as what the
different portions and pathways complete for human behavior. Cerebellum is made up of
different “lobules”, and how each one has a particular job to help human functioning. Asserts
that right hemisphere cerebrovascular accident can manifest behavioral and personality changes,
in decreasing inhibition. It also references that the cerebellum is made up of outer gray brain
matter (slower, less likely to heal) and inner white brain matter (faster, more likely to heal).
CVA and Stroke
Sila and Schoenberg (2011) give a detailed account of the impact of cerebrovascular
disease and stroke. They describe the different types of stroke: ischemic, or a loss of blood flow
to a specific part of the brain, and hemorrhagic: an eruption or burst in a blood vessel, causing a
bleed on the brain (Sila et. al., 2011). In addition, Sila’s literature details each segment of the
brain, and what behaviors, both cognitive and physical will likely demonstrate change if a certain
area of the brain is impacted by stroke/CVA. The most striking information to the researcher is
the notion of rehabilitation and recovery in cortical tissue and patient functioning after a
stroke/CVA. A large percentage of a patient’s functioning will improve as much as possible
during the first three to six months post stroke/CVA (Sila et. al., 2011). Some rehabilitation and
improvement can occur between six and 12 months, but this is generally viewed as adaption,
extensive resources, and increases beyond 9 months post-stroke are positively correlated with a
younger aged patient (Sila et. al., 2011). According to Klinedinst et. Al., (2006) there is also a
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correlation between the levels of education a CVA patient has ascertained; over 70% of the
patients in her study reported as having gone through at least some college education.
Alternative factors in the amount of recovery that a patient may experience is based on
what kind of cortical tissue was impacted; cortical white matter is more likely to recover,
whereas brainstem and midbrain matter is less likely to recover (Sila et. al., 2011). Sila et. al.
(2011) also assert that the most frequently occurring emotional changes that occur in a patient
who has experienced stroke or CVA would be symptoms of anxiety or depression; it’s asserted
that patients who experience a left-hemisphere stroke have symptoms which present with
depressive symptoms, and patients who experience a right-hemisphere stroke demonstrate flat
emotion. Right hemisphere stroke patients are also reported as presenting more frequently with
symptoms of perseveration, as well as symptoms of paranoid thinking (Sila et. al., 2011). One
difference described in the literature regarding symptom longevity and onset is that lefthemisphere patient symptoms tend to resolve over time, whereas the mental health symptoms of
a right-hemisphere stroke patient are less likely to resolve over time (Sila et. al., 2011). When a
patient experiences a stroke on the left hemisphere of the brain, the right side of the body is
impacted; a right hemisphere stroke with affect the left side of the body in the patient.
Mental Health Post Stroke
With the changes in cortical matter in the brain due to physical change and trauma,
frequently so too does a person’s cognitive functioning and mental health. Ukei et. al. (1999)
studied 47 subjects and administered a General Health Questionnaire (GHQ) to find out what
part of the patient’s life was found to be the most debilitated and changed due to the stroke. The
subjects were studied between two and three years after their stroke, and then were administered
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the GHQ. According to the results of the questionnaire, over 38% of the participants marked
ratings above 17, which indicated a presence of a mental health problem in the patient’s life
(Ukei et. al., 1999). The variables studied in the questionnaire were the patient’s age, sex, grade
of motor paralysis, side of motor paralysis, paresthesia, rehabilitation, social support and overall
physical recovery (Ukei et. al., 1999). One of the assessment tools for the research was having
the patient indicate on a plane where patient interpreted their physical recovery was, rating the
recovery either a one, two or three (Ukei et. al., 1999) The results of the study analysis indicate
that the largest predictor of mental health problems in a patient’s life is the patient’s rating of
their subjective assessment of their recovery from the stroke. A significant portion of a CVA
patient experience and mental health status is derived from their own subjective experience of
the situation (Ukei, 1999). The largest predictor of improvement and recovery to the patient was
identified using the patient’s own interpretation of their situation. This literature demonstrates an
importance and benefit to the patients for practitioners and professionals, both serving in mental
and physical health, to view the patient as the expert in their own situation, and use the patient’s
assessment to identify a treatment plan.
Stroke: Issues in Recovery and Rehabilitation
Riddoch et. al. (1995) completed a meta-analysis of various clinical research regarding
interpretation of crucial issues found to be best practice for the stroke/CVA patient. The study
examined general demographics of stroke patients’ in the United Kingdom, indicators of
recovery for patients after stroke, the efficacy of current stroke rehabilitation, the consequences
of stroke on the patient, and questioning the validity of current methodology in the treatment of
stroke patients (Riddoch et. al., 1995). Based on all of the factors examined, the study indicated
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that efforts in treatment planning should be created to suit the needs of individual patients, rather
than using global interventions. The study also suggested that the treatment of stroke patients,
and studies for rehabilitation should be completed by case by case/case study analysis (Riddoch
et. al., 1995). This style of treatment planning and study could be beneficial to stroke/CVA
patients for a number of reasons. Each stroke/CVA tends to be completely different for each
patient; blood loss impacting an area of the brain one millimeter from the impact point of a
different patient can yield completely different physical and cognitive ramifications (Sila et. al.,
2001, p. 301). As each area of the brain serves a different function to the human body, (Sila et.
al., 2011) each symptom and treatment plan too should be planned and viewed on a case by case
basis. Despite a patient primarily presenting with a physical impairment of a stroke, they could
also be experiencing a change in cognition and functioning, but it may not be as apparent to the
practitioner (Riddoch et. al., 1995). Riddoch et. al. (1995) also asserts that “…psychological
systems have a natural tendency to compensate for component limitations and therefore have an
important role to play in rehabilitation.” With this idea, patients who have experienced
stroke/CVA could then be viewed through the lens of a strengths perspective, whereas the
practitioner could assess what part of the patient’s brain hasn’t been impacted as greatly, and
target interventions utilizing this area more in order to help strengthen areas of greater impact.
Work Loss Following Stroke
As a larger percentage of patients who experience stroke/CVA are generally older, less
attention has been given to younger stroke patients (Sila, 2011). With younger stroke patients,
quality of life ratings have been correlated directly with whether or not the patient was able to
return to work or not (Gabriele & Renate, 2009). In addition, the fewer cognitive changes were
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presented for a patient post-stroke, the more likely that patient was to return to work (Gabriele et.
al., 2009). This study compared patient’s ratings of quality of life for 463 patients who either
returned to work or were unable to return to work post-stroke. The findings indicated that not all
patients who did not return to work failed to return as a result of their impairment; as a majority
of stroke patients are older, many chose early retirement rather than returning to work (Gabriele
et. al., 2009) However, the self-described quality was different for younger patients who did and
did not return to work. The quality of life rating was diminished for the younger patients who did
not return to work after one year than it was for the patients who did return to work after one
year (Gabriele et. al., 2009). The research also assessed spousal quality of life ratings with
lifestyle changes for the spouse after stroke/CVA. The statistics demonstrated that the spouse’s
ratings of quality of life had diminished as well, due to new responsibilities: caretaker role,
financial provider, possible loss of future choices, et cetra (Gabriele et. al., 2009). With the
negative impact of stroke on how patients and their spouses live post-stroke, it appears that it
would be beneficial for social workers and treatment planners to identify what efforts can be
made to help these patients and families return to as normal a life as possible after stroke. Since
contribution to personal independence and dependence of family is impactful on quality of life,
finding ways that a stroke patient can lead a life as close to the life they formally had appears to
be critical to stroke patient’s quality of life.
Summary of Literature Review
With the existence of various areas of concern for a patient who experiences CVA, as
well as the support systems of the patient, there exists several areas of concern. These areas of
concern are situations to be identified by both practitioners of medical and psychological
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emphasis. The literature suggests that the functioning of a CVA patient is impacted by the
physical changes in the brain. But the changes in the brain produce significant changes in mental
health and psychological functioning. It is important to the care continuum of patients for
professionals to identify how the psychological and mental health changes will change the
patient’s functioning. As aforementioned, many of the psychological and mental health changes
can go unidentified. With this in mind, it is important for social workers to identify these
changes, and to identify ways in which the stress of these changes can be alleviated. Targeting
the identification of mental health and cognitive dysfunction in CVA patients could help to
produce a better quality of life.
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Conceptual Framework
Ecological perspective
As a stroke, cerebrovascular accident (i.e. CVA) or traumatic brain injury (i.e. TBI) can
impact a person in an instant, so too can all of the support systems in the patient’s life. For
example, a person who has experienced a CVA/TBI and is now bilaterally paralyzed may need
24-hour care, and be unable to financially provide for themselves or their family. This could
make the patient’s inside system become the outside system, if the patient was the sole monetary
provider for the inside system. Inside system is defined by Hutchison (2008) as the patient’s
immediate family or care system. Conversely, the outside system is a reference to groups that the
patient is part of outside of their immediate family (Hutchison, 2008). For example, a patient’s
outside system could involve groups such as a patient’s place of employment, education,
religious systems, et cetra. This event could also impact both going forward through time, as
financial changes could occur, family plans could be altered, and grieving of a foreseeable life
may no longer be a possibility. As all the systems in a person’s ecosystem could be instantly
altered due to stroke, the conceptual framework may be one of the more important Social Work
lenses from which the research should be viewed. Viewing a patient through the ecosystem
model is important, as the percentages of patients having little lifestyle change post-stroke is no
greater than 10% (Fundakin, 2011). A stroke patient may need help moving around the house,
completing activities of daily living, or managing symptoms of change in mental health
functioning. So too could cognitive functioning change, which would increase the necessity of
assistance in functioning from others. Viewing a patient in the context of how the patient
experiences interactions from all support systems around them is why it is important to use the
ecological perspective when conducting this research.
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Cerebrovascular accidents (CVA), strokes or traumatic brain injuries (TBI) can impact a
person’s life in a variety of different ways. These medical experiences generally are not only felt
by the individual, but also felt within the systems that the individual is part of. In this study, the
researcher used the works of Miley, O’ Melia and DuBois (2011), who describe an individual
within that patient’s ecosystem: “…to comprehend human diversity and explicates the
relationship between humans and their environments. The views of human systems as structural,
interactional biopsychosocial, and cultural entities offer a comprehensive and sometimes
complex understanding of system behavior.” Miley et. al. (2011) describes the need to find the
“focal point” within the case being studied. In the case of someone experiencing a CVA or TBI,
the main focal point would be the patient who has experienced the medical situation. However,
depending on the depth of impact the medical condition presents, the support system of the
patient may become permanently integral to the patient’s life. Miley et. al. (2011) identifies
viewing the patient’s systems from five lenses: identifying the focal system, identifying what has
happened inside and outside the support system of the patient, as well as how do the inside and
outside systems connect, and how does the system move through time.
As the primary system being impacted when a patient experiences a stroke, CVA or
traumatic brain injury (TBI) is the patient and their support system. Research will be examined
from the view of the support system or family using the ecological perspective. Per Hutchison
(2011), the ecological perspective examines the behaviors and thoughts of an individual within
the context of the systems and groups of people with which the individual identifies themselves
as the system of analysis. This perspective studying a person’s system as unit of analysis is
further precipitated by examining the person’s family or support system. After experiencing a
stroke, CVA or TBI, the individual can have various parts of their life impacted, but most
17
frequently the individual in context to their family and support system incurs the largest impact.
As Hutchison (2008) asserts, “…social systems are thought to be orderly and remain in a
relatively stable state, also known as homeostasis or equilibrium. Each part of the system serves
an essential function in maintaining the system and the functions of the various parts are
coordinated to produce a well-functioning whole.” After a stroke, a patients’ role, as well as the
roles of others within the individual's systems may significantly change based on the individuals
post-stroke functioning. A role is defined as “…the usual behaviors of persons occupying a
particular social position” (Hutchison, 2008). If the individual post stroke is partially paralyzed,
has cognitive deficits, has a personality change, experiences depression or anxiety, the role of the
individual, as well as the roles of the other persons within that system can change drastically.
Hutchison (2008) goes on to discuss how connected all the members of a system can be, and how
patterns or behaviors are maintained and/or impacted when a person is impacted by the
experienced medical condition.
The ecological perspective was used to orient the research, as the information ascertained
from the subjects not only reflect on the insight of the practitioner, but also the interpretations the
practitioner gained from the patient and the support system of the patient. As the research aimed
to understand what interventions are beneficial to working with a patient who has experienced a
CVA, it is also beneficial to understand what the participants viewed were best practice
interventions when working with the specific patient. The ecological perspective was helpful in
understanding the patient from this lens, as well as all the supports and systems that help this
patient.
The ecological perspective was used to help in the creation process of the interview
items. The emphasis of the research was to ascertain what aspects of the coordination of care
18
hospital social workers find to be most beneficial for stroke patients, as well as the support
systems of said patient. The ecological perspective helped the researcher create questions to help
identify topics viewed by participants as critical to rehabilitation by the patient and support
system. Looking at the rehabilitation process from the view of the patient, the support system of
the patient, as well as the larger culture from which the patient comes from will help to identify
critical areas and principles necessary to rehabilitation.
The researcher decided to ascertain information from the participants via a qualitative
study for a number of reasons. The information gathered from participants via their own
language assisted in gaining more insight to the patient situations via the social workers. Another
advantage to completing a qualitative study for working with this population is in regards to the
unique nature which each patient experiences. As Sila and Schoenberg (2011) assert, strokes can
occur as a result of arterial blockage or arterial hemorrhage, and impact any area of the brain,
from the most basic portion of the brainstem, to the advanced functions of the prefrontal cortex.
Not only does each region of the brain have a vastly different function, but so too does each
partition of each segment. If the participants are able to recall the outcomes of patients based on
the portion of the brain impacted, the planning of after stroke care could be assisted as well. The
qualitative method was used in order to increase the detail and richness of the participant’s
responses. Interviewing the participants rather than having them fill out a survey provided
greater context and detail about their experiences serving stroke patients.
19
Methodology
Research Design
The researcher utilized a qualitative research study design for collecting and examining
the data. This exploratory research design aimed to identify criteria necessary for hospital social
workers to intervene with a CVA patient and family. Through the qualitative interviews of said
social workers, the research aims to find out what factors and symptoms are most influential in
further investigation of the patient. This also includes identifying what mental health symptoms
are most frequently exhibited by the patient to yield further interventions by a social work
professional or practitioner. The overarching question behind this research is: what symptoms do
stroke patients present in order to meet with a physician as well as a clinical social worker? The
literature regarding the challenges of identifying post-stroke depression was used in order to
identify and formulate this research perspective.
Interviews with hospital social workers were conducted. The researcher utilized a
schedule-standardized interview with the participants, using the same questions and order of
questions for all interviews. The researcher created a questionnaire containing both open-ended
and closed-ended questions in order to survey the perspective clinicians.
Research Setting
The researcher interviewed a variety of hospital social workers from hospitals throughout
the Twin Cities metropolitan area. If participants wished not to use their work environment for
the interview, an alternate location was established for the interview.
20
Sample
The researcher interviewed licensed hospital social workers in order to gather
information regarding the protocol for serving clients admitted to a hospital for treatment of a
stroke. The research was completed in order to find out criterion a patient must be categorized
under before the patient was seen by a social worker.
The researcher used snowball sampling to find research participants. The participants
were licensed social workers currently practicing social work in a hospital setting. The researcher
completed an Institutional Review Board (i.e.: IRB) application through the St. Catherine
Universities’ IRB, in order to ensure the participants would not be harmed by participating in the
research project. The inclusion criteria for identifying potential participants are that participants
are a current licensed social worker practicing within a hospital setting at a Twin Cities hospital.
The two social workers on the research committee agreed provided referrals for hospital
social workers who fit selection criteria. Committee members contacted potential participants
using the researcher’s email/flyer. These potential participants who were interested contacted the
researcher. Participants were asked to contact additional potential participants and provided an
email/flyer to hand out.
Protection of Human Subjects
The researcher developed a consent form to give to each participant of the study. The
consent form was approved by the St. Catherine Universities’ IRB, as well as by the research
chair. The entirety of this study was reviewed by the St. Catherine University IRB. During
committee meetings, the researcher, research chair and committee members created a list of
possible subjects to be interviewed for the research project, as well as possible sources of subject
21
identification will also be discussed. The consent form addressed the researcher’s name, contact
information and credentials. The consent form also lists the topics being covered; the intended
procedure of the interview, an approximate length of time the research will encompass, the
potential risks and benefits to the participant, a confidentiality notice, and contact information in
regards to the research chair supervising the researcher. Confidentiality was maintained by the
use of case numbers for each participant, rather than by name. No names of any participant were
used in the final written product. Transcripts were created and maintained on a password
protected computer. Information collected during the interviews were destroyed on or before
May 14th, 2014.
Instrument
The instrument used to identify information during the interviews was in the form of a 17
item questionnaire. The instrument included six demographic questions in order to identify
background information about each participant, and 11 open-ended questions exploring the
unique situations for patients each participant has encountered. Demographic information was
identified during the first portion of the interviews, and largely pertained to the types of Social
Work each participant has served. The subjects of the demographic questions included current
and historic cultures of patients served, number of stroke patients served, type of stroke
experienced by patient, and resources given to the patient and patient support system. The
questions were created through the collaboration of the researcher, the research chair as well as
the research committee members. The open-ended questions were identified using the
information ascertained through the review of literature about stroke patients.
22
The topic areas of the open-ended portion of the interview included areas of the patient’s
life impacted by stroke, list of resources given to patients, mental health symptoms experienced
by the patient, patient requests for medication or mental health therapy, mental health screening
used with the patient, mental health concerns expressed by the caregiving system of the patient,
inclusion of multidisciplinary teams to the treatment of the patient, pervasiveness of social work
services to the patient, and finally supportive counseling services presented. A copy of the items
used in the interviews can be seen in Appendix B.
Data Collection
Data for the research was collected by the use of a schedule-standardized interview
containing a combination of open-ended and closed-ended questions. The researcher obtained
research participants by way of snowball sampling. This method included asking the research
committee members during a committee meeting if they knew of any practitioners who would be
good candidates for the research sample. Once the potential participants were identified, the
researcher asked the participants to identify any other practitioners who could be additional
participants, and so forth. The survey/questionnaire was developed by the researcher by review
of literature pertaining to the topic of CVA and mental health symptom presentation in the
hospital setting. Themes of the survey focused on clinical concerns a patient may present when
experiencing CVA, and compared against symptom presentation of panic/agoraphobia. At the
beginning of each interview, the researcher used several sensitizing, information-gathering
questions and leading questions in order to assess the experience and background of each
participant. Each interview was audio recorded, and subsequently transcribed for theme
identification. After each transcription process, the researcher deleted each interview in order to
23
protect confidentiality. The type of stroke cases that participants tend to encounter are areas
which were assessed during interviews.
Data Analysis
The researcher analyzed the data using a descriptive phenomenological approach (Berg,
2012) in order to identify the themes, sub-themes and manifest content of each interview. The
coding of each of the themes will be described in the future once themes are identified.
The researcher planned to enlist the help of a research assistant to help identify themes
and sub-themes presented by the participant. In addition, the research questions and items were
reviewed by the research committee members, and the committee chair.
Bias
The researcher identifies several possible areas of bias within the field of study, as well as
possible bias during the creation of the survey. As someone who has received hospital services
for a stroke and symptoms of a panic attack, it will be especially important for the researcher to
have several sequences of review for the survey items and questionnaires. This will help to
ensure limiting the impact personal bias presents to the research. The impact of symptoms from
the CVA, as well as the ramifications of mental health symptoms present as historic challenges
to the researcher. Every possible way to limit the impact of personal history from presenting as
bias of the research will be made. The main goal of this research process is to find what
interventions and steps should be taken in order to do the most good for the greatest number of
patients who have experienced CVA or TBI. Limiting personal bias during this process will be of
great importance in order to ensure objectivity during the research process.
24
Personal bias also presents as some possible help to the research process, as it presents as
sensitivity to key issues patients experience post CVA. The experience of CVA also presents as
insight for what other possible ways social workers could intervene with this population.
25
Findings
Sample
The sample for this study was comprised of four licensed female social workers who are
currently employed at three different Twin City metropolitan area hospitals. There were a total of
13 participants contacted by the researcher; 8 were contacted from the initial gathering of sources
from committee members, and five were referrals made by interviewed participants. Length of
time varied amongst participants; the length of time for clinical years experienced varied from
two years, to over 22 years. Initially, over 10 research participants were asked for their
participation for the research, but only one participant responded. However, from this participant,
others were identified via the snowball sampling method, and were then interviewed. The
researcher was provided other referrals from colleagues and supervisors, which provided more
participants. Interviews were completed between 3/20/14 and 4/10/14. Questions one through six
on the interview assessed the participant’s current area of social work practice, previous areas of
social work practice, previous client populations served, number of clients served who have
experienced a stroke, type of stroke experienced by the patient, and resources provided to the
patient. The following tables demonstrate participant’s responses to questions four and five of
the demographic section.
Participants reported serving a variety of numbers of patients; the responses ranged from
100 to 1000-plus patients. Item five of the demographic section asked participants to identify
what type of strokes the patients had experienced. Three of the four participants identified
working with patients who had experienced all types of strokes listed in the item; the fourth was
confident she had served all types, but wasn’t absolutely sure.
26
Themes
As mentioned in the purpose of this study, the aim of the interviews was to identify in
what ways licensed hospital social workers meet the concerns presented by stroke patients and
their support systems. The concerns were identified as abilities to identify and treat mental health
symptoms in patients, concerns experienced by the patient’s care systems, and whether or not
there is a standard social work assessment or tool provided by social workers when working with
stroke patients.
The themes generated by questions six, eight, 10, 11, 12 and 16 did not generate any
themes which corresponded amongst all of the different participants. Question eight created lists
of resources the social workers provide to their stroke patients, and largely varied amongst
participants. Question 10 asked whether or not patients or care systems reported symptoms of
panic attack or agoraphobia, which provided no similar themes. Question 11 enquired about
whether patients or care systems requested medication for mental health symptoms, and each
participant had varying responses as well. Question 12 identified whether or not participants
received requests for mental health therapy from patients or care systems; responses were quite
varied. And finally, question 16 consulted about ongoing services to patients and care systems
provided by the participants. The participants responded with varying answers, which did not
produce an overarching theme. The items which did present themes are listed in the following
themes. Each of the remarks from participants listed in the subsequent tables were quotes taken
from the interviews.
27
The next theme participants identified was that all stroke patients received resources and
referrals from hospital social workers. The most common resources and services administered
during a hospital stay were physical therapy, occupational therapy and speech services. This
question was initially considered to be a demographics question, but three of the four participants
identified themes in their answers:
Table 1.)
6.) When a patient experiences a physical
paralysis, what resources did you give to the
patient or support system?
Participant Two: So those would be resources
where we would have evaluations by
occupational and physical therapists. A lot of
patients I would send to rehabilitation unit,
transitional care unit in nursing homes, or a
more acute level rehab setting, like a sister
Kenny institute or (indistinguishable) rehab.
(Transcript #2, page #9).
Participant Three: So here in the hospital,
they get PT, OT and speech; those are the
primary therapies they get while they’re in the
hospital. (Transcript #3, page 16).
Participant Four: So when they’re here in the
hospital it’s a really short time, and so we
don’t have a lot of time to give resources but
typically what happens is the day after they
come in PT and OT start working with them,
speech if they need it. (Transcript #4, page
#22).
The following items asked participants to identify more detailed information about the
specifics of the patients. When asked about how patient’s lives have been impacted, participants
identified that patients experienced physical impacts and changes, as well as a negative impact
on the patient’s ability to remain independent, or to return to what they defined as “normal life”.
28
Table 2.)
7.) In what ways has the patient’s life been
impacted post stroke?
Participant One: So, full disclosure, right now
in the last 5 years, 10 years working with this
population, most of my patients have severe
physical and severe cognitive deficits from
their brain injury or stroke.(Transcript #1,
page #2).
Participant Two: …and the ability to go back
to their home. Like one patient, his wife was
working on selling their home because it just
wasn’t going to be a possibility to return to
that well below functioning. (Transcript #2,
page #10).
Participant Three: They may be out in the
working world and so they feel that, you
know, now I can’t go back to my job right
away; I’m going to need time to do rehab and
get myself stronger to be able to work. A lot
of these people with strokes are greatly
impacted so they see the outcome as ‘I may
never be able to do this again’. (Transcript
#3, page #16).
Participant Four: There’s people that come in
who were totally independent, and they have
a huge stroke or aneurism and they can’t
work anymore; they don’t have anybody to
care for them; they don’t have insurance so
now they need rehab and don’t have a way to
get it and everything. (Transcript #4, page
#22).
Item 9 in the questionnaire asked the participants to reflect on mental health symptom
presentation by the patients served. Three out of four participants identified that the most
frequently occurring mental health symptom was depressive symptoms.
29
Table 3.)
9.) Have any post-stroke patients
encountered mental health symptoms?
If so, what were some of the
symptoms:
What are the most frequent symptoms
presented?
Participant One: Depression is very common,
and I think situational oftentimes. It gets back
to what we talked about: the adjustment to the
new norm of disability. (Transcript #1, page
#4).
Participant Three: But the ones we do see here
I would say is we see a lot of depression.
(Transcript #3, page #17).
Participant Four: People can be more prone to
depression and anxiety from the stroke, and
so that’s something that everyone kind of
watches for. (Transcript #4, page #24).
Item 13 was asked of the participants to identify mental health screening interventions
which they provide for patients while hospitalized. Three out of four participants identified that
during their initial social work interviews, the participants do ask patients and care systems
whether or not they have identified mental health symptoms in the patient.
Table 4.)
13.) For working with post stroke patients, do
you provide any type of mental health
screening?
Participant One: I assess for that… We do
also have a grief and loss assessment; it’s an
informal tool that we can use to look at the
support… I do some assessment, some more
formal assessments with our initial
assessment about mental health history…
(Transcript #1, page #5).
Participant Three: Usually during our SW
assessment, so that’s the initial assessment
that we do with our patients, were trying to
ID you know is the patient going to benefit
from any mental health services while they’re
here… but just in talking with them during
this initial assessment we try to ID any
concerns that they may have or anything that
30
they’d benefit from, so one of those would be
mental health services. (Transcript #3, page
#18).
Participant Four: … the staff up here is pretty
attuned to what to look for, and so if
somebody is just withdrawing and not
wanting to do anything or if they’re yelling
out or crying. Or talking with the families, if
they’re behaving in a way that’s not “them”,
or normal to them, then we’ll kind of look
more at the mental health piece of it.
Yea, and we meet at team every morning so as
we’re talking about patients, the psychologist
says ‘that sounds like they’d be at risk for
depression/this is what put them at risk’ he
would see them, like I said before, just to
educate them and to keep on top of it.
(Transcript #4, page #26).
Item 14 assessed whether or not participants observed concerns about the impact of the
stroke from the patient, the patient’s care system or a combination of the two. The theme
identified by participants is that concerns are generally presented by both parties, based on the
impact of the stroke on the patient.
Table 5.)
14.) Are the mental health concerns presented
by the patient, or the patient’s support
system?
Participant One: I would really say pretty
close to half and half. It really depends on the
level of deficit for the patient or what
disability…are they even able to ask for
that…they present signs and symptoms maybe
that we see, or can verbalize or request
services, but quite a bit of the time…at least
half of the time its families/support systems.
(Transcript #1, page #6).
Participant Three: We just go in together and
meet with the patient, or patient and family,
31
and kind of really get down to what it is that
they want to set as their goal. (Transcript #3,
page #19).
Participant Four: Probably the support
system. Just kind of noticing that they’re not
themselves or they’re behaving in a way
that’s not congruent with their personality.
(Transcript #4, page #26).
Item 15 identified the amount of multidisciplinary interactions created on behalf of the
patient. All four participants reported positive, helpful working relationships between social
work and other disciplines.
Table 6.)
15.) If the patient is under the care of a
Participant One: We have a very good
medical doctor, do social work and medicine
partnership between the social workers and
connect to complement one another’s service? the physicians. And an interdisciplinary team
that works well together. Which includes
therapy, respiratory therapy, pharmacy,
psychology psychiatry primarily the
specialists… (Transcript #1, page #6).
Participant Two: …yep, absolutely, we very
much functioned as an interdisciplinary team.
I worked with a nurse care coordinator who
would round with the doctor… we round
weekly for our patients. But yeah, certainly
there was a lot of communication
involved…and yeah I think certainly the
doctors would pull you in, or pull me in on
cases where if we needed to have a family
care conference or something like that.
(Transcript #2, page #12).
Participant Three: Yep, I feel like I am talking
to the doctors on a regular basis… And we
work really close with the medical doctors,
and it’s not just the internal medicine doctors,
but neurologists, neurosurgeons…I mean we
have a variety of different people. We work
32
really closely with oncologists as well, if a
patient has a brain tumor up here. (Transcript
#3, page #19).
Participant Four: Maybe not necessarily with
all the doctors, but all the doctors up here are
approachable, and we’ll just page them or
call them if we have any questions, so we stay
in contact with them… (Transcript #4, page
#26).
Finally, item 17 addresses the number of supportive counseling services which are
presented to the patient and support system to be accessed. Each participant identified different
support services, but hospital social workers in each of these settings do provide a plethora of
supportive counseling services to patients and their support systems. The different services are
listed in the following table. Services provided and referred to patients and care systems included
grief support groups, mental health therapy, psychotropic medication evaluation, and education
about the impacts of a stroke.
Table 7.)
17.) Are any supportive counseling services
(I.E.: therapy, grief support, psychoeducation,
etc.) presented to the support systems?
If so, what types of services:
Participant One: We have a brain injury
support group, and it is going on currently…
we’ve had some patient support groups that
have gone well, but then also an emphasis on
family, so with families, we’ve done a
combination of the two, we’ve done outpatient
services to keep connected with impatient,
pulling in the brain injury… and there’s brain
injury support groups for patients and
families of brain injury patients. (Transcript
#1, page #7).
Participant Two: I think the only thing would
be there were some patients where we were
referring them to (indistinguishable) care so
kind of that different supportive
33
environment… So then I think the focus really
is on the family as well as just not the patient.
(Transcript #2, page #13).
Participant Three: Yep, usually we’re trying to
present them with understanding of what a
stroke is… The psychologist does a lot of the
counseling part of it…some of our patients
need to be seen with an outside psychologists,
and we give recommendations to them about,
you know, you should follow up with so and
so regarding your concerns, because we don’t
do a lot of the aftercare…so trying to educate
them on what they’d benefit from in the
community and getting those services for
them while here. (Transcript #3, page #19).
Participant Four: … it’s more for the
community. I know ***** has some support
groups. And there are support groups for
caregivers through the brain injury alliance
also… And I think they really rely more on the
staff here for support while they’re here.
(Transcript #4, page #26).
Another theme identified by two of the participants during the interviews was challenges
in the ability to communicate between patients and social workers due to the effects of certain
types of stroke. No specific interventions or assessments were listed by the responding
participants, but general concern was presented by some of the participants. One participant
reflected that her interventions with a patient consisted of hand-written messages between the
two. Another participant remarked of observed anxiety in patients who lost the ability to speak
and communicate as a result of experiencing a stroke. The topic of finding a way to
communicate with patients who have lost the ability to communicate in ways they once had is
another important topic. As much of social work intervention comes via communication, the
inability for a patient to communicate is a serious area of concern. This theme was generated by
34
comparing participant responses across questions. An example of this theme is demonstrated in
the following quote: … a lot of the patients that aren’t able to communicate…it’s us trying to get
ways to…so I can ID one patient that we worked it out by, he just wrote out things down and
maybe. And so he had wrote down not feeling well, I think was the comment he used. And so
writing back ‘Need to see medical doctor?’ and he wrote ‘no’ and so we communicated back and
forth. Really he just needed someone to talk things through.
35
Discussion
The purpose of the research study was to identify how hospital social workers interact
with stroke patients, and to find out how these social workers are working with symptoms of
mental health being experienced by the patients. The themes generated identified that these
social workers identified mental health symptoms in the patients, but largely referred out mental
health services once the patient was discharged from the hospital.
Sample
The sample of participants was quite representative of the study population, as the
research was conducted only of social workers working with stroke patients within a hospital
setting. The sample was representative of the typical hospital social worker providing services to
a stroke patient, as the participant’s roles were similar to one another. All participants identified
collaborating within multidisciplinary teams in order to identify all of the deficits the stroke has
created for the patient. All of the participants identified referrals to occupational, physical and
speech therapists in order to better identify the patient’s new level of functioning.
The characteristics of the sample may have created impact on their responses due to the
type of hospital served. Three of the four participants reported working with patients who present
to the hospital emergently, and stayed connected to the patient until discharge. The average
discharge reported by these three participants was anywhere from three to ten days after
admission. The fourth worked in a longer term setting, where the patient’s average stay was three
to six weeks. The characteristics of their answers could be different, as three of the four
participants had much less time to work with each patient. The fourth participant could then have
36
had more time to provide services, recommendations and resource identification on behalf of the
patient.
Discussion of Themes
All four participants asserted that physical deficits and loss of independence were areas
of most concern, and the literature articulates that strokes are one of the most frequently
occurring medical conditions leading to long-term disabilities in patients (Klinedinst et al.,
2012). These remarks also coincide with the assertion by Riddoch et. al. (1995) that over
approximately 90% of patients who have experienced a stroke will require some form of
intervention.
Another theme articulated by three of the participants was of the significant presentation
of mental health symptoms, including depression, delirium, confusion and behavioral changes.
This correlates well with Klinedisnt’s assertion that one of the most common mental health
presentations in post stroke patients is post-stroke depression (2012). This theme also resembles
statistics provided by Hackett et. al. (2006) approximately one-third of stroke patients will
experience some form of depression after the stroke.
A reassuring theme presented during the interviews was that all four participants work
closely with an interdisciplinary team in support of stroke patients. The collaborative efforts of
all service providers could lead to an increase in a patient’s functioning. Sila et. al.(2011) asserts
that the highest percentage of patient functioning rehabilitation occurs during the first three to six
months post-stroke. If social work, medicine, psychiatry, occupational therapy, physical therapy
37
and speech are all collaborating on a patient’s behalf immediately post-stroke, there is a higher
likelihood that the patient could regain some of their previous typical lives.
A final result of the interviews which demonstrates support to the literature is the patient
and care system’s accessibility to mental health and supportive services. All of the participants
stated they present patients and care systems with referrals to services like mental health
rehabilitation, medical evaluation, support groups and psychoeducation. Ukei et. al., (1999)
stated that one of the largest predictors of a patient’s capability to recover was the patient’s
interpretation of their current situation. If patients are experiencing depressive symptoms, the
accessibility of mental health services might provide some increase to the patient’s mood,
providing a more positive interpretation of their situation. It was very reassuring to hear that
patients do have the option to speak to someone if they are experiencing a decrease in mood or
depressive symptoms, as these services may just provide the right type of support needed for the
patient during this time.
Researcher Reaction
The process of research and interviewing the participants provided the researcher with
some interactions and insight. A reaction the research presented was due to participants
answering differently than was expected, or proposing questions and topics provided by
themselves. The content presented by the participants provided very interesting content, but
made for a challenge in the coding process. As the research was completed in order to find
certain themes, the response of participant with extraneous content made for considerations of
what to recommend for anyone wanting to continue this research in the future.
38
A reaction experienced by the researcher was the effort necessary to separate the
emotional event and experience of having a stroke from the research project. When participants
shared certain answers which created an emotional reaction in the researcher, it was necessary to
ensure the emotional reaction did not intervene with the interviews. For example, when
participants began to discuss atypical age of stroke patient, the researcher found it necessary to
make sure questions did not change orientation to this area of interest.
In addition, the participants at times made reference and comments about topics to which
they felt most passionate about, which occasionally got off topic from what the item initially
requested. It was an important part of the coding and theme-identification process to make sure
the participants’ off topic responses were identified as themes. This created more challenge in
the coding process, as participants frequently commented on interesting topics worth further
research, but could not be coded for this research process.
39
Limitations and Recommendations
Several limitations to the study were identified. A limitation to this study was the limited
number of participants interviewed. The generalizability of the information gathered could have
increased if there were a greater number of participants to compare the information. One possible
way to remedy the limited number of participants would be to broaden the inclusion criteria to
social workers practicing in settings other than only in a hospital. A possibility to increase
sample size would be to create an online questionnaire and survey. In addition, an increase in
sample size could come from contacting an organization of hospital social workers, such as the
National Association of Social Workers.
One limitation was the acknowledgement of research items being too unspecific. During
one of the interviews, the researcher made reference to the number “25 to 50”, which was a
question about the average number of stroke patients on the participant’s caseload at any given
time. The participant interpreted the numbers as inquiry about patients aged 25 to 50, and
answered the subsequent questions accordingly. The realization that there was such a lack of
definition in the items being questioned, without the ability to change questions in an ad lib
fashion presented as a challenge.
Another limitation was that the respondents of this study social workers providing
services to clients within the acute care setting, and no other types of setting. While this helps to
strengthen the validity of the research and items asked, it decreased the generalizability of the
responses to all hospital social workers. This definition in role for the hospital social worker
defines the type of services which they should be looking for on behalf of the patient. Had these
questions been asked of social workers whom are serving stroke patients after life has calmed for
40
both the patient and the support system, the responses might likely have been considerably
different. A recommendation to others interested in continuing research of social work
interventions with stroke patients would be to specify the participant gathering criteria. This
specificity could lead to the exclusion of acute hospital settings, and focusing more on aftercare
services, such as a setting like the Courage Center, or Sister Kenny. Interviewing social workers
from this service setting, using the exact questions used in this study likely could lead to
different responses, and a differing list of themes identified. For future research, broadening the
participant sample to other social workers serving stroke patients could help broaden the
information gained.
Another recommendation for amending this research design would be the alteration of the
questions asked during the interviews. Some of the interview questions were too vague, and
could be refined to identify more specific information about the social work interventions. For
example, the participant who misinterpreted my comment to be about the average age of the
patient would have led to more specific knowledge. As people younger than 30 years of age
make up less than 10% of the population who has experienced a stroke (Sila et. Al., 2011),
questions asked exclusively about younger patients could lead to a much different result than
what was interpreted for this study.
A limitation was identified during the final committee meeting of the research project.
The limitation identified was of the status of the questions used in the interviews. The questions
created were listed as six demographic-gathering, closed-ended questions, and 11 open-ended
questions. However, when reexamining the questions, it was identified that only item seven was
truly an open-ended question. Items 8 through 16 were actually closed-ended questions, with
41
contingency comments for which the participant could choose to elaborate on. Participants
responded to the items as if they were open-ended, but the research committee was unsure
whether or not the status of items as not truly open-ended impacted the research process at all.
To rectify this occurrence for future studies, a pilot draft of the items could be created and
examined by more researchers or committee members. Another possibility would be to change
the format of the research to be a mixed methods study. This would then identify more questions
as closed-ended, and then could provide elaboration on the open-ended questions.
The information gathered from the participants presented some insight as to why such a
small number of participants responded. One participant referenced responding to the research
study request due to her own involvement in a previous clinical research project. In addition to
this insight, the participant stated email requests need to be prioritized, to ensure continuity of
care for the patients takes precedence over other extraneous requests. With the large number of
patients seen by a social worker, the participants requested who did not respond could have been
too busy to respond to a non-essential request. It could have been that the non-responding
participants were reluctant as they had no personal connection to the researcher.
Another way in which the participants could have been limited was due to the request for
participation via email. The aforementioned participant articulated that the email server
connected to the hospital sometimes will not let outside emails through. This may have presented
as a limiting factor, as some of the requested participants may have never received the request
for participation. A recommendation for further study would be to contact each hospital to
acknowledge the researcher would be emailing social workers as possible participants.
Implications to Social Work
42
One way the findings have provided implications for social workers can be as a result of
the high numbers of people who will experience a stroke in their lifetime. As stated by all of the
participants, each of them have served stroke patients totaling in the hundreds, to possibly the
thousands. According to Klindenst (2012), one in three people in the United States are expected
to die as a direct or indirect result of stroke. With this large number of stroke occurrence, there is
a large likelihood that a social worker will someday come into contact with someone who has
either experienced a stroke themselves, or is dealing with the stress of someone else in their life
experiencing one. This statistic suggests that trainings for working with stroke patients and their
care systems should exist for social workers. As the case of each patient can be very different,
some training should be presented in order to instruct social workers on how best to serve the
myriad of symptoms and problems associated with stroke.
With the likelihood of a stroke patient experiencing some type of depression in their
lifetime (Hackett, 2006), it would be of great importance for clinically-trained social workers to
be meeting with stroke patients on a regular basis. As the participants identified during the
interviews, mental health symptoms, especially depression, is a common experience for someone
who has experienced a stroke. With training on how to identify symptoms of mental health
concern and depression, the service of a clinically-trained social worker could help in the
multitasking roles a hospital social worker is expected to complete. If said social worker is
expected to complete discharge planning, and this social worker has identified depression or
behavioral concerns, the social worker has the ability to identify a placement with all the
resources necessary to serve this patient. It may be of benefit to the hospital social worker if
there existed an inventory for assessing depressive symptoms while in patient is still
hospitalized. As participants mentioned, the demonstration of depressive symptoms is common,
43
but the timing and severity of the symptoms is very different for each patient. If an depression
inventory or screening checklist existed, these symptoms may be more easily identified, and the
outcome of the patient bettered.
In addition, if the patient or care system is not looking for a long-term care placement, a
clinically-trained social worker has the capability of providing counseling services and support
services. The participants reported that their hospitals employ psychologists, psychiatrists and
other mental health rehabilitative workers. If a hospital social worker is licensed as a clinical
social worker, they would have the ability to provide support groups or individual and family
counseling for the patients. With all of the initial anxiety and chaos that can be a result of
someone experiencing a stroke, the social worker has the ability to calm some of these fears for
the patient and care system. With the social worker viewing a patient from the lens of person in
environment, the social worker also has the capability to identify unforeseen problems which
may arise.
The topic of multidisciplinary interaction seemed to be a variable as well as a
commonality during the interviews. As each participant described interactions with
multidisciplinary teams, but to different extents, frequency and team members, there exists
inconsistency across hospitals. The existence of differences in multidisciplinary interactions
could provide variety in the outcome of the patient’s well-being. Research should likely be
continued to find out the preferred amount and content of multidisciplinary interaction on behalf
of a stroke patient.
A topic which emerged during the project, but not addressed by the participants was of
the possibility of clinician or volunteer service providers who themselves have experienced
44
stroke. As all of the participants identified giving patients and families resources, so to could be a
referral to work with someone who has experienced something similar. Receiving support from
someone who is able to answer based on drawing from their own experience may provide solace
and comfort to the patient. If a service provider has experience and knowledge of what a patient
is possibly experiencing, this knowledge may lead to insight into the treatment planning on
behalf of the patient.
45
Conclusion
The purpose of the research study was to identify how hospital social workers interact
with stroke patients, and to find out how these social workers are working with symptoms of
mental health being experienced by the patients. The themes generated identified that these
social workers identified mental health symptoms in the patients, but largely referred out mental
health services once the patient was discharged from the hospital.
The research has provided some insight into the typical interactions a licensed hospital
social worker will experience with a stroke patient. Some of the more pertinent findings from the
interviews reassert that the social workers interviewed are providing evidence-based
interventions with stroke patients. The findings suggest this, as these social workers are
providing education to patients and care systems about what concerns. The participants also
report providing assessments for major areas of concern, the identification depressive and
behavioral symptoms, and equal attention to both the patient and the patient’s care systems.
As aforementioned, the field of research is limited in the ways that psychiatric symptoms
of stroke patients are identified by social workers in a hospital setting. As it is very critical to
ensure psychiatric symptoms are not a side effect of something medically serious in a patient, the
patient’s mental health symptoms are not as emphasized in the initial phase of treating stroke.
For example, panic and anxiety are common symptoms of someone experiencing a heart attack.
But as someone cannot die from the symptoms of a panic attack, the medical situation is of the
greatest importance. The research and knowledge base of identifying depression, anxiety and
panic within the emergency room and hospital setting could benefit from further study.
46
In the example of “Bob” described earlier, the theme of separating physical health and
mental health symptoms could possibly have helped in the patient’s recovery. If more mental
health screening and psychoeducation were presented to the patient, the likelihood of him
returning to the emergency room and hospital for symptoms of panic and anxiety would
decrease. The further study of the interaction between stroke and mental health could help to
streamline the hospitalization process for stroke patients.
47
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Arlington, VA: American Psychiatric Publishing.
Berg, B. L. (2008). Qualitative research methods for the social sciences. Boston, MA: Allyn and
Bacon, 7th ed., (ISBN 0-205-31847-9)
Caplan, B., Moelter, S., Frank, R., & Elliot, T. R. (2000) Stroke. Handbook of Rehabilitation
Psychology. 24, (75-108). Doi: 10.1037/10361-004.
Fundukain, L. J. (2011). The gale encyclopedia of medicine. (4 ed., Vol. 4, pp. 3566-3571).
Detroit, MI: Gale, Cengage Learning.
Hackett, Maree, Anderson & Craig, (2006). Mental health; review finds management of
poststroke depression in elderly is lacking. Mental Health Business Week.
Hiroufumi, U, Washino,K, Fukao, T, Inoue, M, Ogawa, N, Takai, A. (1999). Mental health
problems after stroke. Psychiatry and Clinical Neurosciences. 53. (621-627).
Hutchison, E. D. (2011). Dimensions of human behavior: person and environment. (4th ed.).
Thousand Oaks, CA : Sage Publications, Inc.
Klinedinst, N.J., Dunbar, S.B., & Clark, P.C. (2012). Stroke survivor and informal caregiver
perceptions of poststroke depressive symptoms. Journal of Neuroscience Nursing, 4. (7281). Doi: 10.1097/JNN.0b013e3182477944
Miley, K. K., O'Melia, M., & DuBois, B. (2011). Generalist social work practice. (6th ed.).
Boston, MA: Allyn &Bacon.
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Riddoch, M.J., Humphreys, G. H., & Baetman, A. (1995). Stroke: issues in recovery and
rehabilitation. Physiotherapy, 81. (689-694).
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Rizzo, V. M., (2006). Social work support services for stroke patients: interventions and
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Sila, C & Schoenberg, M.R., (2011) The Little Black Book of Neuropsychology. Springer, NY.
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(1487-1493). Doi: 10.1080/09638280802621432.
49
Appendices
Appendix A
Appendix A
Social Worker Interventions for Patients Post-Stroke
RESEARCH INFORMATION AND CONSENT FORM
Introduction:
You are invited to participate in a research study investigating social work interventions
with patients who have experienced a stroke. The research will examine situations the patient
experiences, both physical and mental, which yield social work intervention in the hospital
setting. This study is being conducted by Alexander Carlson at St. Catherine University under
the supervision of Dr. Michael Chovanec, a faculty member at the university. You were selected
as a possible participant in this research because you are a hospital social worker. Please read
this form and ask questions before you decide whether to participate in the study.
Background Information:
The purpose of this study is to better understand which symptoms a patient experiences
post stroke, including both mental health and physical health problems and how social work
intervenes. Five to ten participants are expected to participate in this research.
Procedures:
If you decide to participate, you will be asked to answer the interviewer’s list of
questions, which is comprised of approximately six multiple choice question and 11 open
ended questions. The questions will be in regards to your work practices, elements of patient
and care system interactions, and patients presenting with symptoms of mental and physical
health complications due to stroke. The research will take place in a confidential setting within
a public building, and will occur only once. This study will take approximately 45 to 60 minutes
over one session and will be audio taped.
Risks and Benefits:
The study has minimal risks. There is a risk that potential difficult memories could be
invoked in the recall of past patient engagements.
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There are no direct benefits to you for participating in this research. This research could further
benefit intervention planning within patients experiencing symptoms of panic or stroke/CVA.
Compensation:
If you participate, you will receive a $10.00 gift card, regardless of completion of the
interview.
Confidentiality:
Any information obtained in connection with this research study that could identify you
will be kept confidential. In any written reports or publications, no one will be identified or
identifiable. Individual quotes will be used in the final paper, but all identifiable information will
be removed from the quotes.
I will keep the research results in a password protected computer once coded into the
SPSS research program, and the audio tape will be locked in a file cabinet at my residence. Only
I and my advisor will have access to the records while I work on this project. I will finish
analyzing the data by May 25th, 2014. I will then destroy all original reports and identifying
information that can be linked back to you. The memory card containing the interview will be
erased on or before May 25th, 2014
Voluntary nature of the study:
Participation in this research study is voluntary. Your decision whether or not to
participate will not affect your future relations with myself or St. Thomas/St. Catherine
University in any way. You may refuse to answer any of the survey items if you so choose. If
you decide to participate, you are free to stop at any time without affecting these relationships,
and no further data will be collected. The gift card will still be distributed if you choose to meet
for any part of the interview. You are free to suggestions of questions or topics during the
interview.
Contacts and questions:
If you have any questions, please feel free to contact me, Alexander Carlson, at (651)2350818. You may ask questions now, or if you have any additional questions later, the faculty
advisor, Dr. Mike Chovanec: (651) 690-8722, will be happy to answer them. If you have other
questions or concerns regarding the study and would like to talk to someone other than the
researcher(s), you may also contact Dr. John Schmitt, Chair of the St. Catherine University
Institutional Review Board at (651) 690-7739.
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You may keep a copy of this form for your records.
Statement of Consent:
Your signature indicates that you have read this information and your questions have
been answered. Even after signing this form, please know that you may withdraw from the study
up to one week after signing, and no further data will be collected.
______________________________________________________________________________
I consent to participate in the study, and I agree for my interview to be audio-taped.
_______________________________________________________________________
Signature of Participant
Date
_______________________________________________________________________
Signature of Researcher
Date
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Appendix B
Hospital Social Worker Interventions with Stroke Patients
As stated in the consent form, you are free to withdraw from the research at any time.
Please answer to your best ability. If you are unsure how to answer any item, or feel
uncomfortable answering any items, please feel free to say so. During section one of the
interview, the research will begin with items aimed at identifying what types of patients you have
served in the past. Section two will spend more time in identifying specifics to the types of
services you have provided to this clientele. If you have any questions at any time, please feel
free to clarify.
Questions for research interview:
Section 1 – Demographics
1.) What area of social work do you work in currently?
2.) Are there any other areas of social work in which you have worked? (For example, school, inhome services, other hospital settings, community mental health setting, etc.)
3.) What client populations have you historically worked with? (For example, children, students,
clients with serious and persistent mental illness, homeless, etc.)
4.) How many clients have you served who’ve experienced a stroke?
a.) 1-5 patients
b.) 6-12 patients
c.) 13+ patients
5.) If you can recall, what types of strokes have these patients experienced? (please circle all that
apply)
a.) Ischemic or Hemorrhagic
b.) Left/Right hemisphere
c.) Prefrontal Cortex
d.) Parietal
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e.) Thalamic
f.) Cerebellar
g.) Pons
h.) Brainstem
i.) Midbrain
j.) Other
6.) When a patient experiences a physical paralysis, what resources did you give to the patient or
support system?
a.) Physical Therapy
b.) Occupational Therapy
c.) In-Home Services
d.) Skilled Nurses
e.) Family or support system resources If so, please list ________________________________
f.) Emotional or Behavioral support
g.) Psychotherapy
h.) Other (please list)_________________________________________________________
6.) How do patients get referred to your type of services?
a.) Primary Care Physician
b.) Physical/Occupational Therapist
c.) Support System Inquiry
d.) Other (please list)______________________________________
Section 2: Open-ended
7.) In what ways has the patient’s life been impacted post stroke?
54
8.) Is there a standard list of resources you give to patients of stroke? If so, what is it composed
of?
9.) Have any post-stroke patients encountered mental health symptoms?
If so, what were some of the symptoms:
What are the most frequent symptoms presented?
10.) Have any patients/family systems reported symptoms of panic/agoraphobia?
If so, what were symptoms:
If so, was a rehabilitative service recommended? What was the service recommended?
11.) Do any of the patients request medication for their mental health symptoms?
If so, what percentage?
12.) Do patients/support systems ever request mental health therapy for their symptoms?
13.) For working with post stroke patients, do you provide any type of mental health screening?
14.) Are the mental health concerns presented by the patient, or the patient’s support system?
15.) If the patient is under the care of a medical doctor, do social work and medicine connect to
complement one another’s service?
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16.) Are social work services an ongoing service to these patients?
17.) Are any supportive counseling services (I.E.: therapy, grief support, psychoeducation,
etc.) presented to the support systems?
If so, what types of services:
Any other thoughts/ideas/themes that I haven’t asked about that you care to remark on?
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS INTERVIEW!
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Appendix C
Are you a hospital Social Worker?
Have you ever provided any care for patients who have experienced a stroke?
Have you ever worked as part of a multidisciplinary team to provide care for these patients?
Do you have ideas on possible interventions for working with stroke patient?
If you said “yes” to any of the questions above, I would like to invite you to participate in
a clinical research project interviewing licensed hospital social workers. The aim of the research
is to find out what situations you find to be problematic for the patient, as well as the patients’
care system, who has experienced a stroke. If there are ideas or situations you have found to be
beneficial to working with this population, or not as beneficial, I would like to hear your opinion!
I will be conducting a one session per participant interview and survey about situations
and issues of concern facing hospital social workers who have experience serving the stroke
patient population. The surveys are expected approximately 45 to 60 minutes, and will assess
approximately 12 to 15 open ended questions about the service of this population.
For your time and participation, I will provide a $10 gift card, regardless of whether or
not you complete the entire survey.
If you have any interest, please feel free to contact Alex Carlson at (651)235-0818 or at
[email protected]. I will be able to provide answers to any questions you may have about
the process, and the intent behind the survey. Survey times are expected to begin in early
February and run until late March. I will arrange for days and times which work best for
participants, as well as find whatever area will be best for the interview.
Thank you so much for your time and consideration!